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IN 2009, the centers for disease control reported that fewer than 10 percent of U.S. high school students are eating the combined recommended daily amounts of fruits and vegetables. Also in 2009, a study was released that found that supplementation with multivitamins during the first years of life may reduce the risk of allergic disease at school age. Two years earlier, an international study lasting 12 months reported that even in well-nourished school-aged children, fortification with multiple micronutrients can result in improvements in verbal learning and memory.

At least on its face, there is a good case to be made
for vitamin and mineral supplementation for children and
adolescents. Research increasingly is showing that the diet
and everyday environmental factors during the first three to
five years of life can have important consequences in the areas
of mental health, educational performance and the ability to
interact socially. Similarly, early nutrition helps to determine
whether the child will grow up obese, develop diabetes
or suffer from heart disease in later life. In adolescents,
nutritional support improves concentration and other aspects
of performance and behavior.

Infant nutrition is a harder case and not as clear-cut. It
long has been known that an infant’s diet is important for
mental development. On the one hand, the mother’s eating
habits, especially consumption of omega-3 fatty acids, and
overall health during pregnancy may contribute greatly to her
child’s health and even determine her child’s risks for major
diseases in adulthood. On the other hand, it is difficult to
intervene nutritionally at just the right level during the first six
months of life. In part this is because it is easy with infants to go
beyond the accepted tolerable upper limit of intake for certain
nutrients, especially vitamins A and folic acid and the mineral
zinc. The one fortification that most researchers would agree is
justified is an increased intake of the omega-3 fatty acids.

Starting children off on the right foot
It is clear that Americans have been losing the earliest of
nutritional battles. For instance, obesity has reached epidemic
proportions in children. Estimates are that 25 percent of children
in the U.S. are overweight and an additional 11 percent are obese.
This is cause for concern given that children who are obese at
age 4 have a 20 percent risk of being obese in adulthood. If
they continue to be overweight as adolescents, they have an 80
percent chance of being overweight or obese as adults.

With obesity comes diabetes. According to Dr. Lori Laffel, head
of the pediatric unit at Boston’s Joslin Diabetes Center. “Over the
years, we always saw an occasional child with type 2 [diabetes]. It
was a handful a year.” That was before the 1990s, when overweight
parents began to bring in their similarly large children with type
2 diabetes. In that decade, the number of children with so-called
“adult” diabetes increased approximately 500 percent, and the
rate has doubled again since then. Similar increases are reported
at other institutions. Regarding this type of diabetes in children,
Dr. Phillip Lee, head of pediatric endocrinology at UCLA, says, “we
just didn’t see it. Now referrals of type 2 are almost 50 percent
of our diabetes cases.” Diabetes and pre-diabetes (also called Syndrome X or the metabolic syndrome) ominously are linked to not just obesity, but hypertension, cardiovascular disease and yet other conditions.

Before considering supplements as a solution to
childhood nutritional problems, two issues need to be tackled.
First, there is the problem of diet. Especially sugar in the
diet. Keep in mind that sweetened drinks, not just sodas,
but the sugared 10 percent juice drinks, have almost totally
displaced water in the lives of modern American children.

Food nutritionists at Cornell University during a two-month
study found that children do not reduce how much food they
eat at meals to match the number of calories they consume
in sweetened drinks. Instead, the more sweetened drinks
they consume, the greater their daily caloric intake and the
greater their weight gain. According to David Levitsky, this
survey of 30 children aged 6–12 supports previous findings
that excessive sweetened drink consumption adversely affects
nutrition and promotes obesity in school-age children. For the
purposes of this study, sweetened drinks included fizzy drinks,
fruit punch, and bottled tea or drinks made from fruit-flavored
powders, such as grape and lemonade. According to the study,
children who drank more than 16 ounces a day of sweetened
drinks consumed four ounces less milk than children who
avoided sweetened drinks. Their diets supplied 20 percent
less phosphorus, 19 per cent less protein and magnesium, 16
percent less calcium and 10 percent less vitamin a plus less
zinc even though these children also took in 244 more calories
a day from these beverages. The ingestion of sweetened drinks
led to the consumption of only 2 ounces less solid food,
although such drinks routinely displaced milk.

Second, and on the other side of the energy equation,
children now exercise less than in previous generations.
According to a study by the Centers for Disease Control, 22.6
percent of American children (aged 9–13) do not engage in
any free-time activity. Nearly two-thirds of these children do
not participate in any organized physical activity during their
non-school hours.

Nutrient recommendations for children
Multivitamin—mineral supplementation for children does not
need to involve heroic amounts of nutrients. In fact, trials exhibiting
success in already supposedly well-nourished children
often have involved daily vitamin-mineral supplementation at
only roughly 50 percent of the U.S. Recommended Daily Allowance
(RDA) for 3 to 14 months versus placebo. Depending on
the study, benefits have been demonstrated in the areas of attention-
concentration, verbal learning and memory, non-verbal
intelligence and overall behavior. The impact is especially noticeable
in children with antisocial and delinquency traits, but
benefits routinely have been found, as well as, in children and
teens supposedly beyond any need for nutritional intervention.
A major recent review of 20 randomized placebo-controlled trials
concluded, “multiple micronutrient supplementation may
be associated with a marginal increase in fluid intelligence
and academic performance in healthy school children but
not with crystallized intelligence.”

Dietary Reference Intake (DRI) tables have been developed
by the Institute of Medicine’s Food and Nutrition Board and
are available from various sites on the Internet. Here is one of
these resources:

Inasmuch as the tables are copyrighted, they cannot be
reproduced here. The main points to keep in mind are these:
first, supplementation does not need to be at high levels
to deliver benefits. Many or even most successful trials
supplemented only on the order of 50 percent of suggested
daily intakes. Second, the suggested intakes of nutrients
vary with age, body size, sex and activity. Let’s take vitamin
B1 (thiamin) as an example of how age and sex can influence
requirements. Children 1–3 years old require 0.5 Mg/day, 4–8
years require 0.6 Mg/day, boys 9–13 years require 0.9 and
boys 14–18 require 1.2 Mg/day, this last being also the typically
required adult male intake level. Girls aged 9–13 years also
have a recommendation of 0.9 Mg/day, but only 1.0 Mg/day
at ages 14–18 years and then 1.1 Mg/day at age 19 and older.
Parents need not slavishly adhere to nutrient tables. The
point is to find a general and broad spectrum multivitamin
and mineral supplement that supplies roughly 50–100 percent
of nutrients for the age of the child. Just “being in the ballpark”
usually is good enough.

Nutrient recommendations for teenagers
From the perspective of an adult, most teenagers are eating
machines. As with children, at the present time teenagers
are likely to consume predominantly “empty” calories. Most
American teens do not take vitamins and even among those
who do take supplements, several micronutrients usually
are consumed at inadequate levels. In one study, more than
one-third of adolescents had dietary intakes of vitamins A
and E, calcium, and zinc that were less than 75 percent of the
U.S. Recommended Dietary Allowance. Recommendations
here are as with children: find a general and broad spectrum
multivitamin and mineral supplement that supplies roughly
50–100 percent of recommended nutrients for the age, gender
and activity level of the adolescent in question.

Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)
Besides the recent disturbing trends towards obesity and
diabetes in children and adolescents, the most significant
concern in American children may be the incidence of ADD/
ADHD. According to the National Institute of Mental Health
(NIMH), ADHD affects approximately 2 million American
children or approximately 3 to 5 percent of the school-age
population and is about four times more common in boys
than in girls. ADHA usually becomes apparent at about age 3.
Symptoms include inattention, inability to concentrate, failure
to listen when spoken to, hyperactivity, squirming, talking out
of turn, impulsiveness, disruptive behavior, sleep problems,
and poor learning ability.

A number of nutritional scientists argue that ADHD
is a birth defect caused by deficiencies of maternal DHA
(docosahexaenoic acid) during pregnancy and while nursing, and the virtual absence of DHA and AA (arachidonic acid) in infant formulas. DHA in particular is required to support fetal
visual acuity, neurological and brain development in the womb
and in early life. As a point of information, AA is a long-chain
omega-6 fatty acid found primarily in meat and eggs, whereas
the omega-3 fatty acids EPA (eicosapentaeonoic acid) and
DHA are found primarily in the fat of cold-water fish. A related
omega-3 fatty acid, alpha-linolenic acid (ALA), is found in flax
and pumpkin seeds, walnuts, and in eggs from hens raised on
grass or special diets instead of grains. Even meat and butter
from animals raised on grass (rare in the U.S. today) may
provide substantial amounts of ALA.

ADD/ADHD is highly controversial. At a consensus development
panel conducted by the National Institutes of Health
on ADHD in November 1998, it was reported, “we do not have
an independent, valid test for ADHD, and there are no data
to indicate that ADHD is due to a brain malfunction. Further
research to establish the validity of the disorder continues to
be a problem. This is not unique to ADHD, but applies as well
to most psychiatric disorders...” Some doctors report various
brain metabolic imbalances, but these, too, are controversial.

There was a 2.5-fold increase in the prevalence of methylphenidate
(Ritalin) treatment of youths with ADD between
1990 and 1995 in the United States. In all, approximately 2.8
percent (or 1.5 million) of U.S. youths aged 5 to 18 were receiving
this medication in mid-1995. Data for treatment rates in
the U.S. is inconsistent. One Journal of the American Medical
Association (JAMA) article published in 1998 estimated that 3–6
percent of the school-aged population is being treated with
psychotropic drugs, mostly stimulants. Noteworthy is the fact
that a U.K. review from 2004 found that in that country in
1999 the rate of treatment for ADD in boys was 5.3 Per 1,000
boys—that is, one tenth the rate of the U.S.! This suggests
that there is either some terrible environmental flaw present
in the U.S. or some terrible error in diagnosis of ADD/ADHD
in this country.

There also is the issue of treatment. In animals, exposure
to Ritalin (methylphenidate) during developmental stages
damages the personality. According to William Carlezon of
McLean Hospital and Harvard Medical School in Boston, a primary
researcher in this area, “rats exposed to Ritalin as juveniles
showed large increases in learned-helplessness behavior
during adulthood, suggesting a tendency toward depression.”

Obviously, the implications of the above are serious, and even
more so when it is realized that ADD/ADHD stimulant drugs,
such as Ritalin, work only for the first few months of treatment.

At most, the good effects may last 14 months. Moreover, the
FDA in 2009 actually had to urge caution in interpreting a study
linking stimulants to increased risk for sudden death in children.

Food additives and colors long have been suspected of
inducing ADHD in susceptible individuals. Diets that eliminate
such food adulterants sometimes have proved to be wildly
successful, reducing symptoms in the range of 78 percent in
comparison with controls. This was a diet of containing only
rice, meat, vegetables, pears and water for five weeks. When
restricted foods were added back to the diet, there was a relapse
rate of 63 percent. Especially pernicious may be food colors and
sodium benzoate.

Finally, there are some safe and practical suggestions
for supplementation that may help. Chief among these is
supplementation with omega-3 fatty acids. German scientists
found a beneficial effect with a combination of omega-3
and omega-6 fatty acids as well as magnesium and zinc
consumption on attentional, behavioral, and emotional
problems of children and adolescents. Some trials indicate
that even zinc supplementation by itself may be beneficial if a
particular protocol is followed.

The supplement alpha-lipoic acid has been used
successfully in a study at UCLA to improve the symptoms
of adult ADHD sufferers. Inasmuch as lipoic acid improves
blood sugar regulation and the utilization of glucose by the
brain, this suggests a prediabetes link to ADHD. Barry Sears
has written that contradictory results with regard to omega-3
supplementation may be expected because some studies tend
not to control dietary intake of high-glycemic carbohydrates
(sugar and starch), and do not provide their study groups with
sufficiently high doses of DHA and/or EPA. For whatever reason,
almost no attention has been paid to the insulin resistance
aspect of ADHD, yet ADHD is highly prevalent among obese
patients and highest in those with extreme obesity. A recent
European review found that empirically based evidence
suggests that obese patients referred to obesity clinics may
present with higher than expected prevalence of ADHD and all
reviewed studies indicate that subjects with ADHD are heavier
than expected. One common causal mechanism linking ADHD
and excessive weight is a disruption in the “reward” receptors of
the brain based on the chemical dopamine. Recent work shows
that the excessive consumption of sugars actually alters brain
receptors such that individuals in the future feel the need—
based on lasting changes in brain physiology and chemistry—
to eat sugar and other refined carbohydrates.

Concluding Thoughts
Children and adolescents often can benefit from nutritional
supplementation. For most, a simple multivitamin and mineral
supplement providing 50 to 100 percent of the currently
suggested daily intake of vitamins and minerals may be enough.
For others, especially those who are performing below par in
terms of attention, memory, verbal functioning and emotional
balance, additional omega-3 and omega-6 fatty acids as well
as magnesium and zinc, perhaps alpha-lipoic acid, may be in
order. Reducing the consumption of sugars and other refined
carbohydrates and increasing physical activity almost always is
a good practice, as well.

Dallas Clouatre, PhD

Dallas Clouatre, Ph.D. earned his A.B. from Stanford and his Ph.D. from the University of California at Berkeley. A Fellow of the American College of Nutrition, he is a prominent industry consultant in the US, Europe, and Asia, and is a sought-after speaker and spokesperson. He is the author of numerous books. Recent publications include "Tocotrienols in Vitamin E: Hype or Science?" and "Vitamin E – Natural vs. Synthetic" in Tocotrienols: Vitamin E Beyond Tocopherols (2008), "Grape Seed Extract" in the Encyclopedia Of Dietary Supplements (2005), "Kava Kava: Examining New Reports of Toxicity" in Toxicology Letters (2004) and Anti-Fat Nutrients (4th edition).

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